MSK conditions :howell Flashcards
Juvenile idiopathic arthritis definition
chronic,systemic inflammatory condition that begins before age 16
begins in at least one joint for at least 6 weeks
on exam, defined as joint swelling or a combination of limited range of motion with pain in a joint
JIA incidence
(peak incidences)
more common in women (2:1)
2 peak incidence:
1. 1-3 years old
2. 8-12 years old
JIA 3 course patterns
highly variable
monophasic: active systemic, gone after 4-6 months with no recurrence
polycyclic: long periods of inactivity with active episodes (least common)
persistent (Chronic): variable forms (systemic sx wit no srthritis, both systemic and arthris sx, arthritis no systemic sx) most common
JIA labs
ESR:
systemic and polyarticular= increased
pauciarticular = normal
anemia= in chronic JIA
high WBC( as white cells entry sybovium they can cause decrease in serum especially in active dz)
(-) RF
ANA: in 33% of children with ocular complications in pauciarticular
JIA evaluation
soft tissue swelling
periarticular osteopenia
joint destruction (less frequent in children) erosions and cysts
JIA management
eye exams/ophto referral: every 3 months
(+) ANA in 33% of pauciarticular JRA out of this, 10% have chronic uveitis
(-) ANA monitor every 6 months: chance of developing chronic uvitis is diminished each year ANA(-)
at 5 years post-diagnosis monitoring is no longer cost effective
JIA complications
blindness: most serious for pauciarticular
joint deforminity: more common in polyarticular JRA
intermittent infections and potentially fatal amyloidosis for protractes systemic JRA
mortality overall is 2%
types of JIA , incidence and when is it determined
determined the first 6 months based on sx’s
systemic aka “still’s disease” (20%) , younger childen
Pauciarticular/oligoarticular (50%) most common
polyarticular (30%)
Systemic JRA aka still’s disease
diagnostic criteria
diagnostic criteria: fever at least 2 weeks in duration and quotidian= daily intervals where it spikes several times throught the day
must also have one of the following:
typical rash: linear pattern, salmon color, maculopapular, worse with fever and evenings , elicited by scratching (koebner’s phenomenon)
LAO,HSM
or serositis (pericarditis, pleuritis)
Systemic juvenile idiopathic arthirtis sx
systemic sx more pronounced than articular sx (within first 6 months)
maybe one joint with mild inflammation
Systemic juvenile idiopathic arthirtis labs
mild anemia
elevated: ESR,CRP
Negative: ANA and RF
infectious workout: blood cultures, urine, joint tapping all negative
malignancy workup
Pauciarticular/oligoarticular JRA onset and prognosis
onset:2-3 yrs old
good prognosis
Pauciarticular/oligoarticular JRA sx
swelling, pain, and stiffness in 2-4 joints
larger joints: knees (very common), elbows, ankles : limping when walking
systemic sx minimal: spiking fevers are not common
eye involvement: higher risk than other JRA
chronic iriidocyclitis manifestation of anterior uveitis
risk of perm vision loss
leg length discrepency of affected leg
before pubertery: leg longer due to synovial thickening
after: leg shorter bc hrowth pltes stop sooner
pauciarticular/oligoarticular subgroups
persistent: no additional joint involvement after the first 6 months
extended: involvement of additional joints after first 6 months
Polyarticular JRA sx
more likely to persist to adulthood
5 or more joints involved: swelling, pain and stiffness
resembles adult RA: symmetric pattern
C-spine involvement common: decreased ROM and pain in the neck
may have systemic features but less severe than systemic JRA
micrognathia: early closure of ossification centers of the mandible, marked receding of chin, characteristic of polyarticular jra
HSP(Henoch-schonlein purpura definition and peak age
a vasculitic syndrome
inflmmation of small blood vessels
peak age: 4-7 years old
HSP triad
purpura
colicky(abd pain, cramping that comes and goes)
migratory arthritis
HSP complications
renal disease: hematuria/proteinuria
rare condition but urine analysis is needed to rule this out
Rheumatic fever etiology
multisystemic inflammatory disease after strep throat group a strep, B hemolytic step pyogenes
rheumatic fever incidence
ages 5-15 y/o for first attack
possible relapses later
rheumatic fever rash
erythema marginatum
serpiginous rash
evanescent: worse w/fever
well demarcated spreading to trunk and proximal extremeties
not specific
lasts a day or so
jones criteria major and minor
one major and 2 minor or 2 major and evidence of strep pharyngitis
Major criteria:
migratory polyarthritis (70%)
carditis (40-50%)
chorea (Syndenhams)
erythema marginatum
subcutaneous nodules: extensor surfaces on
minor:
(+) thorat culture or rising ASO titer
fever
arthalgia
increased acute phase reactant
CRP and ESR elevated
Prolonged PR interval on EKG
Evaluation of rheumatic fever
throat culture
ASO titer
chest x-ray
echo
note: valvular defects and mitral valve leaflet prolapse may show up later in life
Rheumatoid arthritis etiology
unknown. perhaps autoimmune or infectious agent
Rheumatoid arthritis incidence
peak ages: 35-45 years old
prevalence increases with age
3x more common in females
genetics: association with HLA DR4 “dang RA”
twin to twin concordance:15-20%
rheumatoid arthitis onset types
70% insidious in onset
20% subacute
10 % explosive or acute
RA inflammation process
edema leads to neovascularization
synovial linig thickers (hyperplasia)
erosion occurs at the joint margins
inflmmation leads to seroous effusion
effucion stretches the joint capsule
the joint becomes unstable
deformities form
RA sx
fatigue. malaise, wt loss
symmetrical
small and proximal joints 1st: MCPs, PIPs, wrist, MTPs : larger joints later
better with activity
common RA hand deformities
fusiform swelling: 1st sign
PIP swelling (synovitis)
sausage finger or spindle shaped
Boutonniere deforminty: flexion of PIP joints and extension at DIP joint
Swan neck: flexion at MCP joint, extension at PIP, flexion at DIP joint
ulnar deviation of fingers
subluxation of the MCP
RA extra-articular manifestations
tendonitis and tendon ruptures
pulmonary
peripheral nerve compression: carpal tunnel
rheumatoid nodules: strongly associated with positive RF
splenomegaly
pericarditis
vacultiis
eye involvement: scleritis, dry eyes, epi-scleritis: inflmm of thin membrane between the sclera and conjuctiva
RA labs
supportive but not diagnostic
positive RF in 70-80% of pts
evelated CRP and ESR
mild anemia of chronic dz
high WBC count : 60% are neurtophils
synovial analysis: arthrocentesis shows fluid is cloudy, sterile, decreased viscosity, no crystals
X ray findings RA
Soft tissue swelling
periarticualr osteopenia: bone loss near the joint
joint space narrowing
erosion
deformity
RA diagnostic criteria
all of the following are present
inflmmatory arthritis in 3 or more joints
+RF and/or anti-CRP aka ACPA
elevated ESR or CRP
sx for longer than 6 weeks
excluding other causes
dx for patients not meeting criterai
seronegative RA (lack both RF and ACPAS)
Based upon findings otherwise characteristic of RA if appropriate exclusions have been met
recent onset of ra
To avoid delays in initiation of treatment for pts with severe disease presentation
increased mortality in RA
shortens life span by 5-10 years
cardiovascular complications
infections: 5x higher risk than general population
cancer and lymphoproliferative malgnancies : 5-8x higher risk of lymphoma
other clinical problems:
sjogren’s
osteoporosis
laryngeal manifestation
ossicles of the ear: tinnitus and decresead hearing
RA management
early diagnosis and treatment necesary to prevent damge
no weight bearing exercising
poool therapy exercise
nsaids for sx releif
DMARDs: disease modifying anti-rheumatic drugs
assignment by rheumatoligst
methotrexate (MTX), gold, cyclosporin,immunran
hydrochloroquine : anti malaria drug, safer
Felty syndrome
1-3% of RA
very high RF
RA in combination with splenomegaly, leukopenia, thrombocytopenia
HLA DR4+
usually occurs after many years of aggressive RA
pulmonary and skin infections common
